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1.
Clin Transplant ; 38(2): e15262, 2024 02.
Artigo em Inglês | MEDLINE | ID: mdl-38369849

RESUMO

INTRODUCTION: The nature, intensity, and progression of acute pain after bilateral orthotopic lung transplantation (BOLT) performed via a clamshell incision has not been well investigated. We aimed to describe acute pain after clamshell incisions using pain trajectories for the study cohort, in addition to stratifying patients into separate pain trajectory groups and investigating their association with donor and recipient perioperative variables. METHODS: After obtaining IRB approval, we retrospectively included all patients ≥18 years old who underwent primary BOLT via clamshell incision at a single center between January 1, 2017, and June 30, 2022. We modeled the overall pain trajectory using pain scores collected over the first seven postoperative days and identified separate pain trajectory classes via latent class analysis. RESULTS: Three hundred one adult patients were included in the final analysis. Three separate pain trajectory groups were identified, with most patients (72.8%) belonging to a well-controlled, stable pain trajectory. Uncontrolled pain was either observed in the early postoperative period (10%), or in the late postoperative period (17.3%). Late postoperative peaking trajectory patients were younger (p = .008), and sicker with a higher lung allocation score (p = .005), receiving preoperative mechanical ventilation (p < .001), or VV-ECMO support (p < .001). CONCLUSION: Despite the extensive nature of a clamshell incision, most pain trajectories in BOLT patients had a well-controlled stable pain profile. The benign nature of pain profiles in our patient population may be attributed to the routine institutional practice of early thoracic epidural analgesia for BOLT patients unless contraindicated.


Assuntos
Dor Aguda , Transplante de Pulmão , Adulto , Humanos , Adolescente , Estudos Retrospectivos , Toracotomia , Transplante de Pulmão/efeitos adversos , Manejo da Dor , Dor Pós-Operatória/etiologia
2.
Transplantation ; 107(7): 1573-1579, 2023 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-36959119

RESUMO

BACKGROUND: In this international, multicenter study of patients undergoing lung transplantation (LT), we explored the association between the amount of intraoperative packed red blood cell (PRBC) transfusion and occurrence of primary graft dysfunction (PGD) and associated outcomes. METHODS: The Extracorporeal Life Support in LT Registry includes data on LT recipients from 9 high-volume (>40 transplants/y) transplant centers (2 from Europe, 7 from the United States). Adult patients who underwent bilateral orthotopic lung transplant from January 2016 to January 2020 were included. The primary outcome of interest was the occurrence of grade 3 PGD in the first 72 h after LT. RESULTS: We included 729 patients who underwent bilateral orthotopic lung transplant between January 2016 and November 2020. LT recipient population tertiles based on the amount of intraoperative PRBC transfusion (0, 1-4, and >4 units) were significantly different in terms of diagnosis, age, gender, body mass index, mean pulmonary artery pressure, lung allocation score, hemoglobin, prior chest surgery, preoperative hospitalization, and extracorporeal membrane oxygenation requirement. Inverse probability treatment weighting logistic regression showed that intraoperative PRBC transfusion of >4 units was significantly ( P < 0.001) associated with grade 3 PGD within 72 h (odds ratio [95% confidence interval], 2.2 [1.6-3.1]). Inverse probability treatment weighting analysis excluding patients with extracorporeal membrane oxygenation support produced similar findings (odds ratio [95% confidence interval], 2.4 [1.7-3.4], P < 0.001). CONCLUSIONS: In this multicenter, international registry study of LT patients, intraoperative transfusion of >4 units of PRBCs was associated with an increased risk of grade 3 PGD within 72 h. Efforts to improve post-LT outcomes should include perioperative blood conservation measures.


Assuntos
Transplante de Pulmão , Disfunção Primária do Enxerto , Adulto , Humanos , Transfusão de Eritrócitos/efeitos adversos , Disfunção Primária do Enxerto/diagnóstico , Disfunção Primária do Enxerto/etiologia , Disfunção Primária do Enxerto/epidemiologia , Estudos Retrospectivos , Transplante de Pulmão/efeitos adversos , Pulmão
3.
J Cardiothorac Vasc Anesth ; 36(9): 3596-3602, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35641410

RESUMO

OBJECTIVES: Controlling moderate-to-severe pain remains a major challenge after cardiothoracic surgery. Several outcomes have been compared extensively after valve surgery performed via midline sternotomy versus mini-thoracotomy, but postoperative pain (POP) was not adequately examined. Therefore, the authors tested the hypothesis that there is no difference in POP trajectories in patients undergoing valve surgery via midline sternotomy versus mini-thoracotomy. DESIGN: An Institutional Review Board-approved retrospective study. SETTING: At a single, large academic medical center. PARTICIPANTS: Adult patients who underwent mitral or aortic valve surgeries over a 5-year period. INTERVENTIONS: The authors compared the characteristics of pain between valve surgery patients receiving either midline sternotomy or mini-thoracotomy. To identify pain score trajectories, the authors employed latent class linear mixed models and then used multinomial regression models to study the association between incision type and pain trajectory class. MEASUREMENTS AND MAIN RESULTS: The authors' cohort consisted of 1,660 surgical patients-544 (33%) received a midline sternotomy, and 1,116 (66%) received a mini-thoracotomy. The authors identified the following 4 pain trajectory classes: stationary, rapidly improving, slowly improving, and acute worsening pain. Compared to the rapidly improving class, the odds of belonging to the stationary (adjusted odds ratio [aOR] [95% CI] 1.45 [1.01- 2.08]; p = 0.04) or the acute worsening class (aOR [95% CI] 1.71 [1.10-2.67] p = 0.02) were significantly higher for sternotomy patients compared to mini-thoracotomy. CONCLUSIONS: Midline sternotomies are associated with higher odds of having an acute worsening or stationary versus a rapidly improving pain trajectory compared to mini-thoracotomies. Therefore, the choice of incision may play an important role in determining POP trajectory after valve surgery.


Assuntos
Implante de Prótese de Valva Cardíaca , Esternotomia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Dor , Estudos Retrospectivos , Esternotomia/efeitos adversos , Toracotomia/efeitos adversos , Resultado do Tratamento
4.
J Thorac Cardiovasc Surg ; 164(5): 1351-1361.e4, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35236625

RESUMO

OBJECTIVE: To clarify the relationship between the use of extracorporeal life support during lung transplantation and severe primary graft dysfunction (PGD), we developed and analyzed a novel multicenter international registry. METHODS: The Extracorporeal Life Support in Lung Transplantation Registry includes double-lung transplants performed at 8 high-volume centers (>40/year). Multiorgan transplants were excluded. We defined severe PGD as grade 3 PGD (PGD3) observed 48 or 72 hours after reperfusion. Modes of support were no extracorporeal life support (off-pump), extracorporeal membrane oxygenation (ECMO), and cardiopulmonary bypass (CPB). To assess the association between mode of support and PGD3, we adjusted for demographic and intraoperative factors with a stepwise, mixed selection, multivariable regression model, ending with 10 covariates in the final model. RESULTS: We analyzed 852 transplants performed between January 2016 and March 2020: 422 (50%) off-pump, 273 (32%) ECMO, and 157 (18%) CPB cases. PGD3 rates at time point 48-72 were 12.1% (51 out of 422) for off-pump, 28.9% for ECMO (79 out of 273), and 42.7% (67 out of 157) for CPB. The adjusted model resulted in the following risk profile for PGD3: CPB versus ECMO odds ratio, 1.89 (95% CI, 1.05-3.41; P = .033), CPB versus off-pump odds ratio, 4.24 (95% CI, 2.24-8.04; P < .001), and ECMO versus off-pump odds ratio, 2.24 (95% CI, 1.38-3.65; P = .001). CONCLUSIONS: Venoarterial ECMO is increasingly used at high-volume centers to support complex transplant recipients during double-lung transplantation. This practice is associated with more risk of PGD3 than off-pump transplantation but less risk than CPB. When extracorporeal life support is required during lung transplantation, ECMO may be the preferable approach when feasible.


Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Pulmão , Disfunção Primária do Enxerto , Ponte Cardiopulmonar/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Transplante de Pulmão/efeitos adversos , Transplante de Pulmão/métodos , Disfunção Primária do Enxerto/diagnóstico , Disfunção Primária do Enxerto/etiologia , Disfunção Primária do Enxerto/terapia , Estudos Retrospectivos , Transplantados , Resultado do Tratamento
5.
JAMA Surg ; 157(1): e215856, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34787647

RESUMO

Importance: Inhaled nitric oxide (iNO) is commonly administered for selectively inhaled pulmonary vasodilation and prevention of oxidative injury after lung transplant (LT). Inhaled epoprostenol (iEPO) has been introduced worldwide as a cost-saving alternative to iNO without high-grade evidence for this indication. Objective: To investigate whether the use of iEPO will lead to similar rates of severe/grade 3 primary graft dysfunction (PGD-3) after adult LT when compared with use of iNO. Design, Setting, and Participants: This health system-funded, randomized, blinded (to participants, clinicians, data managers, and the statistician), parallel-designed, equivalence clinical trial included 201 adult patients who underwent single or bilateral LT between May 30, 2017, and March 21, 2020. Patients were grouped into 5 strata according to key prognostic clinical features and randomized per stratum to receive either iNO or iEPO at the time of LT via 1:1 treatment allocation. Interventions: Treatment with iNO or iEPO initiated in the operating room before lung allograft reperfusion and administered continously until cessation criteria met in the intensive care unit (ICU). Main Outcomes and Measures: The primary outcome was PGD-3 development at 24, 48, or 72 hours after LT. The primary analysis was for equivalence using a two one-sided test (TOST) procedure (90% CI) with a margin of 19% for between-group PGD-3 risk difference. Secondary outcomes included duration of mechanical ventilation, hospital and ICU lengths of stay, incidence and severity of acute kidney injury, postoperative tracheostomy placement, and in-hospital, 30-day, and 90-day mortality rates. An intention-to-treat analysis was performed for the primary and secondary outcomes, supplemented by per-protocol analysis for the primary outcome. Results: A total of 201 randomized patients met eligibility criteria at the time of LT (129 men [64.2%]). In the intention-to-treat population, 103 patients received iEPO and 98 received iNO. The primary outcome occurred in 46 of 103 patients (44.7%) in the iEPO group and 39 of 98 (39.8%) in the iNO group, leading to a risk difference of 4.9% (TOST 90% CI, -6.4% to 16.2%; P = .02 for equivalence). There were no significant between-group differences for secondary outcomes. Conclusions and Relevance: Among patients undergoing LT, use of iEPO was associated with similar risks for PGD-3 development and other postoperative outcomes compared with the use of iNO. Trial Registration: ClinicalTrials.gov identifier: NCT03081052.


Assuntos
Epoprostenol/administração & dosagem , Transplante de Pulmão , Óxido Nítrico/administração & dosagem , Vasodilatadores/administração & dosagem , Administração por Inalação , Adulto , Feminino , Rejeição de Enxerto , Humanos , Masculino , Prognóstico
6.
J Cardiothorac Vasc Anesth ; 34(7): 1733-1744, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32430201

RESUMO

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.


Assuntos
Anestesia , Anestesiologia , Ventilação Monopulmonar , Humanos , Pulmão , Cirurgia Torácica Vídeoassistida
8.
Ann Thorac Surg ; 110(1): e23-e25, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31981503

RESUMO

Patients who are undergoing lung transplantation may require systemic anticoagulation in the perioperative period for various indications at the time of the procedure. Four-factor prothrombin complex concentrate has been approved in the United States to reverse the effects of warfarin for patients requiring urgent surgery. We describe a perioperative anticoagulation strategy with warfarin that is reversed before incision using 4-factor complex concentrate for off-pump lung transplant recipients.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Transplante de Pulmão , Assistência Perioperatória/métodos , Trombose/prevenção & controle , Transplantados , Varfarina/uso terapêutico , Adulto , Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Humanos
9.
Semin Cardiothorac Vasc Anesth ; 24(1): 96-103, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31617443

RESUMO

Chronic pain after lung transplantation is a significant concern, in particular given the heterogeneity of the patient population and the challenges of achieving adequate pain control amid concerns related to complex immunosuppressant regimens and the possibility of respiratory depression. We undertook a patient-reported outcomes (PRO) survey administered via our electronic health care portal to examine the postoperative incisional pain prevalence in a cohort of lung transplant recipients at a single, high-volume center where bilateral thoracosternotomy is the preferred surgical approach. The Patient Reported Outcomes Measurement Information System (PROMIS) Global Health and Pain Intensity short forms were sent to a total of 173 lung transplant recipients who were more than 2 months postsurgery at the time of the study. A total of 64 patients responded to both PROMIS surveys (response rate 38%). In the cohort of survey respondents, we observed a chronic pain incidence of 58% after lung transplantation (median pain score 1/10) and an overall good quality of life score (median score 4/5); however, only 9.4% reported moderate-severe pain (pain score ≥5/10). Survey nonrespondents had higher rates of pretransplant opioid and psychiatric medication use compared with respondents. In this study, we demonstrated the feasibility of using an electronic PRO survey for assessing postoperative pain outcomes after lung transplantation. However, measuring pain outcomes using this type of tool highlights issues of response rate and potential selection bias. Larger studies are needed to adequately assess the risk and predictors of chronic pain after lung transplantation and its impact on quality of life.


Assuntos
Dor Crônica/epidemiologia , Transplante de Pulmão/métodos , Dor Pós-Operatória/epidemiologia , Qualidade de Vida , Adulto , Idoso , Analgésicos Opioides/administração & dosagem , Dor Crônica/etiologia , Feminino , Humanos , Imunossupressores/administração & dosagem , Incidência , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Prevalência , Estudos Retrospectivos , Viés de Seleção , Inquéritos e Questionários
10.
J Cardiothorac Vasc Anesth ; 33(5): 1382-1392, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30193783

RESUMO

The syndrome of frailty for patients undergoing heart or lung transplantation has been a recent focus for perioperative clinicians because of its association with postoperative complications and poor outcomes. Patients with end-stage cardiac or pulmonary failure may be under consideration for heart or lung transplantation along with bridging therapies such as ventricular assist device implantation or venovenous extracorporeal membrane oxygenation, respectively. Early identification of frail patients in an attempt to modify the risk of postoperative morbidity and mortality has become an important area of study over the last decade. Many quantification tools and risk prediction models for frailty have been developed but have not been evaluated extensively or standardized in the cardiothoracic transplant candidate population. Heightened awareness of frailty, coupled with a better understanding of distinct cellular mechanisms and biomarkers apart from end-stage organ disease, may play an important role in potentially reversing frailty related to organ failure. Furthermore, the clinical management of these critically ill patients may be enhanced by waitlist and postoperative physical rehabilitation and nutritional optimization.


Assuntos
Fragilidade/cirurgia , Insuficiência Cardíaca/cirurgia , Transplante de Coração/métodos , Pneumopatias/cirurgia , Transplante de Pulmão/métodos , Assistência Perioperatória/métodos , Fatores Etários , Fragilidade/diagnóstico , Fragilidade/fisiopatologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Humanos , Pneumopatias/diagnóstico , Pneumopatias/fisiopatologia , Transplante de Pulmão/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle
11.
Reg Anesth Pain Med ; 42(6): 764-766, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29016551

RESUMO

INTRODUCTION: Patients undergoing minimally invasive cardiac surgery have the potential for significant pain from the thoracotomy site. We report the successful use of pectoral nerve block types I and II (Pecs I and II) as rescue analgesia in a patient undergoing minimally invasive mitral valve repair. CASE REPORT: In this case, a 78-year-old man, with no history of chronic pain, underwent mitral valve repair via right anterior thoracotomy for severe mitral regurgitation. After extubation, he complained of 10/10 pain at the incision site that was minimally responsive to intravenous opioids. He required supplemental oxygen because of poor pulmonary mechanics, with shallow breathing and splinting due to pain, and subsequent intensive care unit readmission. Ultrasound-guided Pecs I and II blocks were performed on the right side with 30 mL of 0.2% ropivacaine with 1:400,000 epinephrine. The blocks resulted in near-complete chest wall analgesia and improved pulmonary mechanics for approximately 24 hours. After the single-injection blocks regressed, a second set of blocks was performed with 266 mg of liposomal bupivacaine mixed with bupivacaine. This second set of blocks provided extended analgesia for an additional 48 hours. The patient was weaned rapidly from supplemental oxygen after the blocks because of improved analgesia. CONCLUSIONS: Pectoral nerve blocks have been described in the setting of breast surgery to provide chest wall analgesia. We report the first successful use of Pecs blocks to provide effective chest wall analgesia for a patient undergoing minimally invasive cardiac surgery with thoracotomy. We believe that these blocks may provide an important nonopioid option for the management of pain during recovery from minimally invasive cardiac surgery.


Assuntos
Bloqueio Nervoso Autônomo/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Fáscia/diagnóstico por imagem , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Medição da Dor/métodos , Nervos Torácicos/diagnóstico por imagem , Idoso , Anestésicos Locais/administração & dosagem , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Fáscia/efeitos dos fármacos , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Medição da Dor/efeitos dos fármacos , Nervos Torácicos/efeitos dos fármacos
13.
A A Case Rep ; 4(10): 140-2, 2015 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-25974419

RESUMO

We present the case of a 53-year-old female Jehovah's Witness with nonischemic cardiomyopathy who successfully underwent a bloodless heart transplantation using fibrinogen concentrate (RiaSTAP; CSL Behring, King of Prussia, PA) and other blood-conservation methods. With a multidisciplinary team and the use of preoperative erythropoietin-stimulating drugs, normovolemic hemodilution, cell salvage, and pharmacotherapy to prevent and treat coagulopathy, we were able to maintain hemoglobin levels greater than 11 g/dL without the need for blood transfusion. We conclude that orthotopic heart transplants may be performed successfully in select Jehovah's Witness patients using standard and novel blood conservation methods.


Assuntos
Procedimentos Médicos e Cirúrgicos sem Sangue/métodos , Transplante de Coração/métodos , Testemunhas de Jeová , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/ética , Cardiomiopatias/sangue , Cardiomiopatias/cirurgia , Epoetina alfa/administração & dosagem , Feminino , Fibrinogênio/uso terapêutico , Hematínicos/administração & dosagem , Hemoglobinas/metabolismo , Humanos , Pessoa de Meia-Idade , Religião e Medicina , Resultado do Tratamento
14.
Semin Cardiothorac Vasc Anesth ; 18(1): 45-56, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24336691

RESUMO

Pain after thoracic surgery can be severe and, in the acute phase, contribute to perioperative morbidity and mortality. Unfortunately, patients also incur a significant risk of chronic pain. Although there are guidelines for postoperative pain management in these patients, there is no widespread surgical or anesthetic "best practice." Here, we review the recent literature on techniques specific to perioperative pain control for thoracic patients, including medical management, neuraxial blockade, and other regional techniques, and suggest an algorithm for developing a multimodal pain management strategy.


Assuntos
Dor Pós-Operatória/terapia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Toracotomia/efeitos adversos , Dor Aguda/etiologia , Dor Aguda/terapia , Algoritmos , Anestésicos/administração & dosagem , Dor Crônica/etiologia , Dor Crônica/terapia , Humanos , Guias de Prática Clínica como Assunto , Síndrome , Procedimentos Cirúrgicos Torácicos/métodos , Toracotomia/métodos
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